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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601574
Report Date: 08/28/2025
Date Signed: 08/28/2025 12:45:49 PM

Document Has Been Signed on 08/28/2025 12:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:CARTAGENA HOMEFACILITY NUMBER:
198601574
ADMINISTRATOR/
DIRECTOR:		MARIA CHRISTINA SERAFICOFACILITY TYPE:
735
ADDRESS:1306 CARTAGENA STREETTELEPHONE:
(562) 988-8142
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 4CENSUS: 3DATE:
08/28/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Maria Christina SeraficoTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On August 28, 2025, Licensing Program Analyst (LPA) Deborah Lee arrived at the facility listed above to conduct an unannounced Case Management-Other visit to follow up on death report. LPA met with Maria Cristina Serafico and explained the purpose of the visit.

LPA is following up on report of a death in the facility. Incident/death report sent to the Department regarding the following: On 7/9/25 C1 passed away of pneumonia at approximately 11:44am at Whittier Medical Center.

The Case Management visit consisted of:

On 8/28/25, LPA obtained and reviewed the following: C1’s physical exam (dated 6/26/25), Individual Program Plan (IPP) from Placement Agency (dated 12/10/24), Medication list (dated 6/20/25 ).

On 8/28/25, LPA conducted 2 staff interviews: Administrator (A1) and (S1)

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CARTAGENA HOME
FACILITY NUMBER: 198601574
VISIT DATE: 08/28/2025
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The Case Management visit revealed the following:

On 8/28/25 at 9:15am, LPA interviewed Administrator (A1) who stated that based on C1's IPP, C1 does have a history of respiratory issues which predates C1's move to the facility. According to A1, on 6/29/25, C1 appeared to be congested and was having trouble breathing which prompted S1 to call emergency medical services at approximately 6:15am. C1 was transported to Long Beach memorial [accompanied by S1] where C1 received a chest x-ray and laboratory testing. C1 was transferred to Whittier Medical Center due to an insurance issue. Subsequently, C1 was admitted to the hospital and treated for Pneumonia. On 7/9/25 C1 passed approximately 11:44am at Whittier Medical Center. A1 stated that the placement agency and management team was notified along with the Unusual Incident Report (UIR) sent to CCL. Lastly, A1 informed LPA that C1 has no family involvement so the placement Agency serves as C1’s responsible party.

On 8/28/25 at 10:45am LPA interviewed S1 who stated that at approximately 6:00am when she came on shift the Noc (overnight) staff informed her that C1 was congested so they had to reposition C1. S1 stated that she checked on C1 and she and another staff member “sat C1 up in C1's wheelchair." S1 further stated that C1 was still “struggling” so S1 called 911 approximately 6:30am. S1 informed LPA that she accompanied C1 to the hospital and stayed with C1 through the transfer to Whittier Medical Center where C1 was admitted.

On 8/28/25, LPA obtained/reviewed C1’s current physician’s report (dated 6/26/25) and medication list (dated June 2025 ) and Individual Program Plan (IPP) from placement agency (dated 12/10/24). The IPP reports C1’s history of respiratory issues.

There were no deficiencies cited during today’s visit.

Exit interview conducted and copy of report was provided.

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NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Deborah Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
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